Provider Demographics
NPI:1790445708
Name:KUFORIJI, MUTIAT
Entity Type:Individual
Prefix:
First Name:MUTIAT
Middle Name:
Last Name:KUFORIJI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21141 SOPHIA DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1869
Mailing Address - Country:US
Mailing Address - Phone:773-629-9754
Mailing Address - Fax:
Practice Address - Street 1:21141 SOPHIA DR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1869
Practice Address - Country:US
Practice Address - Phone:773-629-9754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041464352163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse